Membership Form

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Membership Form

Fill in the form below to apply for membership to the Committee. Print out the completed form and mail it in with your payment in US$ drawn on a US bank. Annual Dues are $35.00

Membership Type: * New Member Renewal

Your Information

Name: * First: * M.I.: Last: *
Address 1: *
Address 2:
City: * State: * Postal Code: *
Country: *
Home Phone: * Work Phone: Fax:
Your Email Address: *

Information About Your Organization

Name: *
Address 1:
Address 2:
City: State: Postal Code:
Country:
Phone Number: Fax Number:

Your Title / Position:

$35.00 dues (Jan. 1 to Dec. 31)

+ Contribution to Virginia Hazzard Memorial fund:
+ Other contribution:
= Total payment by check payable to NGO Committee on Ageing in US$ drawn on a US bank:

Please complete and mail this form with payment to:
NGO Committee on Ageing
c/o Dr. Richard Velayo
130 Water Street, 4-A
New York, NY 10005

The NGO Committee on Ageing